Class 6: Dementia and Hypoxia Flashcards
What is hypoxia?
Deficient amount of oxygen to tissues of the body
(in our case the brain tissue)
Altered / not sufficient cardiac or respiratory function.
Diffuse effect neurocognitively.
Ex. near drowning, cardiac arrest, massive blood loss, car accident with multiple internal injuries with massive bleeding.
What is hypoxemia?
Deficient amount of oxygen in the blood
What are traditional causes of hypoxia?
COPD Obstructive sleep apnea (OSA) Acute respiratory distress syndrome (ARDS) High altitude COVID
What can influence the lung and how the individual is oxygenating with COPD?
Inflammation of airways that obstruct the airways, mucous, further on out into lungs more narrow airways get. Alveoli can lose shape and flexibility.
How can COPD affect cognition?
Encoding/retrieval memory; problem solving, verbal fluency, working memory, psychomotor speed, simple motor skills
Exercise can positively impact this
How can sleep apnea affect cognition over a period of time?
Sustained/selective attention
Psychomotor speed, fine motor coordination
Planning, initiation, mental flexibility, working memory, verbal fluency
Learning and memory
What does neuroimaging show for involvement of deficits for sleep apnea?
Reductions in prefrontal cortex, subcortical gray matter, hippocampus, white matter
What are neurologic manifestations of COVID?
Olfactory and gustatory
Cognition (Brain fog)
Dizziness, headaches
1/3 of patients on discharge exhibited cognitive and motor deficits
What are neurologic consequences of COVID?
Mild but real brain damage
Encephalitis
Acute inflammation of the brain
Cause viral infections
Brain swelling
Strokes
Increase risk for people over 70 and in the young (7x more likely)
Damage to white matter connections
Small vessel disease, lacunar infarcts, “mini strokes”
Systemic Inflammation
Associated with cognitive decline with ongoing / lasting effects
Increase in proinflammatory cytokines (found in severe sepsis) associated with hippocampal atrophy
What is the most common type of dementia?
Alzheimer’s
What is dementia?
An acquired, progressive impairment of several cognitive domains in an alert individual
NOT delirium or psychiatric disorder
Influences social interactions, work, and ability to perform ADLs
Secondary to a disease of the brain (e.g., AD, PD) that are typically chronic in nature.
What can dementia impair?
Memory Reasoning Orientation Calculation Learning capacity Language Judgment Deterioration in emotional control, social behavior or motivation
What can dementia impair?
Memory Reasoning Orientation Calculation Learning capacity Language Judgment Deterioration in emotional control, social behavior or motivation
What is the DSM 5?
Diagnostic and Statistical Manual of Mental Disorders
Published by the American Psychiatric Association to relay a common language and classification system for mental disorders
What are the classifications of disorders in the DSM 5?
Major Neurocognitive and Mild Neurocognitive Disorder
What is a mild neurocognitive disorder?
Evidence of modest cognitive decline from a previous level of performance in one or more domain based on the concerns of the individual, a knowledgeable informant, or the clinician
Measurable memory impairment on standardized testing; outside range of expected for age / education matched healthy older adults
Cognitive deficits are INSUFFICIENT to interfere with independence (e.g., instrumental activities of daily living – paying bills, managing meds) but greater effort, compensatory strategies or accommodation may be required to maintain independence.
NOT secondary to delirium or another mental disorder (DSM 5)
What is delirium?
Disturbance in attention and orientation to the environment; confusion.
Disturbance develops over a short period of time (hours to days) and represents and acute change from baseline that is not solely attributable to another neurocognitive disorder.
Fluctuates in severity during the course of the day
Not related to neurocognitive dysfunction!
What causes delirium?
Medications (especially anti depressants, antipsychotics) Most common Infections Metabolic disorders Surgery, anesthesia Substance withdrawal Kidney or liver disease Toxins
What is major neurocognitive disorder?
Evidence of substantial cognitive decline from a previous level of performance in one or more of cognitive domains based on the concerns of the individual, a knowledgeable informant, or the clinician.
Test performance in the range of 2 or more SD below appropriate norms
Cognitive deficits are SUFFICIENT to interfere with independence (i.e., requires min assist with instrumental ADLS)
Not secondary to delirium or another mental disorder
What requirements must major neurocognitive impairment meet?
Symptoms must be insidious in onset
Must not be accounted for by delirium, schizophrenia or major depression
Must be acquired
Must be persistent (does not vary like delirium)
Must cross several areas of cognitive function
Must be severe enough to interfere with work, social activities and relationships with others
What are risk factors of MCI to turn into AD?
Age APOE carrier status (APOE e4). Found on chromosome 19 Can be inherited by mother, father or both Present in 25 to 30% of the population and 40% of people with late onset AD RISK FACTOR…not a cause. DM HTN Increased Cholesterol
What can prevent AD?
Absence of APOE 4 variant Lifetime of exercise (physical and mental) Youth Social stimulation Controlled cardiovascular risk Non-smoking
Examples of changes of memory in normal aging?
Forget appointment
Forget a neighbors name
Forget a birthday or anniversary
What are examples of changes in memory in dementia and major CI?
May not remember making an appointment
May not recognize a neighbor or family member
My not recognize that their spouse’s birthday is February 4
Examples of disorientation in normal aging?
Forgets day of week, gets lost
Examples of disorientation in dementia or major CI
Routinely do not know what day it is
May not recognize if it is morning, noon or night
May get lost in their own neighborhood or home
What are examples of lapses in judgement in normal aging?
Dress inappropriately for the weather
Unintentionally violate social conventions
Examples of lapses in judgement in dementia or major CI
Wear a wool coat on a hot day
Address strangers as close friends
Examples of difficulty performing mentally challenging tasks
May make a mistake when balancing the checkbook
Difficulty programming a new smart phone
Example of difficulty performing tasks with dementia and major CI
Unable to perform simple calculations
Difficulty remembering what a microwave is for
Examples of misplacing things in normal aging
Occasionally misplace regular things
Examples of misplacing things dementia and major CI?
May put regularly used items in an odd place – purse in the refrigerator, cell phone in the cookie jar
Examples of changes in mood in normal aging?
Experience a wide range of emotions in response to life events
Examples of changes in mood in dementia and major CI?
May exhibit rapid changes in mood that occur for no apparent reason or for trivial reasons.
What is the hallmark sign of Alzheimer’s disease?
Selective changes in episodic and working memory in the early stages.
Beginning in the hippocampus (medial temporal lobe) and enthorhinal cortex
What is a neurofibrillary tangle?
Threadlike structures normally found in the cell bodies, dendrites, axons and sometimes in the synaptic endings of neurons in the brain get tangled and clumped together.
What is a neuritic plaque?
Minute areas of tissue degeneration consisting of granular deposits. Cause significant reduction in neuronal synapses which impact transmission.
What areas are most effective early on in AD?
Most frequently affect the temporoparietal-occipital junctions and the inferior temporal lobes
What areas are spared in early on AD?
Frontal lobes, the motor and sensory cortex and the occipital lobes usually are spared in the beginning
Language impairments involved in early stage AD
Episodic memory is usually the earliest and most prominent manifestation of AD
Phonology, syntax, articulation and voice quality are all well preserved
Mild word retrieval problems
Recognize and try to correct
Occasional mild verbal paraphasia
Subtle comprehension impairments
Functional reading comprehension for newspapers and articles – difficulty with longer length/more complex information
Automatics are preserved
Decreased sustained attention and mental flexibility
Adequate conversationalists
Difficulty with humor, sarcasm, verbosity, difficulty maintaining topic
Communication features of middle stage AD?
Word finding problems become obvious in conversation and increased difficulty noted with self correction
Increased sentence fragments and ungrammatical sentences
Reading rate declines and eventually becomes nonfunctional for all but the most familiar material
Recreational reading is abandoned
Increased apathy and withdraw from conversation
Passive conversational partners
Offer trivialities and irrelevant comments in place of substantive contributions
Comprehension of nonliteral material is grossly impaired
Communication features of middle stage AD?
Word finding problems become obvious in conversation and increased difficulty noted with self correction
Increased sentence fragments and ungrammatical sentences
Reading rate declines and eventually becomes nonfunctional for all but the most familiar material
Recreational reading is abandoned
Increased apathy and withdraw from conversation
Passive conversational partners
Offer trivialities and irrelevant comments in place of substantive contributions
Comprehension of nonliteral material is grossly impaired
Communication features of late stage AD?
Communication is severely compromised
Reading is nonfunctional
Recognize highly familiar words
Writing is nonfunctional
Over learned items
Comprehension is limited to short words and phrases
Speech – single words which are often bizarre and devoid of meaning
Syntax breaks down and increased neologisms noted
Unaware of errors and make no attempt to self correct
Non functional conversationalists
Fail to observe social conventions
Insensitive to conversational rules
Dwell on past experiences
Communication features of very late stage AD
Mute or echolalic
Pallilalic (endless repeating of self generated words or phrases)
Looses all orientation to self and surroundings
Neuropathologic hallmarks of late stage AD
Cortical association areas severely involved
Only primary sensory and motor areas spared
What is vascular dementia?
Caused by ischemic cerebrovascular disease or circulatory disturbances
What are risk factors of vascular dementia?
multiple strokes, HTN, DM II, smoking, hypercholesterolemia
What are cognitive effects of vascular dementia?
Perform better with memory tasks and worse with attention and executive function vs AD
What is dementia with lewy bodies?
Results from abnormal clumps of neuronal protein in the cortex
What are symptoms of lewy bodies dementia?
Symptoms overlapping AD, however with early symptoms of visual or other sensory hallucinations, visual spatial impairment, sleep disturbance, fluctuating attention
Gait imbalances or PD features
Reduced speech rate, fluency
Memory typically preserved
What is frontotemporal lobar degeneration
Accounts for 10% of dementias
Most diagnosed prior to 65 yo (45-60)
Significant impairment in behavior, personality and language impairment
What are the three domains affected by frontotemporal lobar degeneration
Personality
Language
Motor Skills: motor neuron disease,
Primary Progressive Aphasia is a type of?
Frontotemporal lobar degeneration
What are the three types of primary progressive aphasia?
Semantic Variant: fluent speech with loss of semantic knowledge
Nonfluent variant
Logopenic Varient
What are examples of subcortical dementias?
Parkinson’s Disease
Huntington’s Disease
Progressive Supranuclear Palsy
What are features of subcortical dementia?
Motor impairments typically are prominent in the early stages
Memory, intellect, language impairments appear months to years after the appearance of motor impairment
Features of Parkinson’s disease?
Muscle rigidity Tremor Loss of balance Loss of swing of arms Shuffling narrow gait
What cognitive factors are impaired by parkinson’s disease?
Memory – new learning, inferencing
Attention – divided, selective attention, speeded tasks
Visual – visual discrimination, synthesis
Executive – problem solving, working memory, planning, set-shifting, cognitive flexibility, verbal fluency (often the first symptom)
What are characteristics of huntington’s disease?
Chorea (ceaseless, rapid, repeated movements) Cognitive decline Neurobehavioral symptoms Personality changes Agitation Depression Paranoia delusions
What are the cognitive effects of huntington’s disease?
Memory first
Slowing intellectual functions and compromised attention
What is progressive supranuclear palsy?
Resembles Parkinson’s
Rigidity (neck and trunk vs arms and limbs)
Slowness of movment
Difference – absence of tremors
Many are first dx with Parkinson’s disease
What is is the neuropathology of progressive supranuclear palsy?
Neuronal loss
Neuronal abnormalities
Proliferation of glial cells throughout the brain stem and basal ganglia
Cortical neurons are largely spared
What are the symptoms of progressive supranuclear palsy?
Loss of vertical movements of the eyes Increased risk of falls Loss of lateral movements of the eyes Limbs become stiff and rigid Dysarthria Dysphagia (common cause of death: aspiration pneumonia or resp. failure) depression
What will late stages of progressive supranuclear palsy involve?
Slowing of mental processes and increasing forgetfulness
Final stages – mute, immobile, dependendant
What is Creutzfeldt-Jakob Disease?
Extremely rare, rapidly progressive and fatal. Dementia is almost always present Memory impairments Slowed mental processes Impaired reasoning/problem solving Motor discoordination Flattened affect Rapidly deteriorates
